Healthcare Provider Details

I. General information

NPI: 1427055102
Provider Name (Legal Business Name): MARK RICHARD ROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 FRANCISCAN DR
BRYAN TX
77802-2544
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-5967
  • Fax: 979-731-5619
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberJ8112
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA48234
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberJ8112
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: